Epstein Secrets

ALTH HISTORY (Serious Illnesses Inures explain) (attach narrative it additonal space needed) C. I ARARATARY Ina inelinlaelli e Tuberculin test Sickle Cell type date result NAME: TITLE: ADDRESS: (Please Print) r-rdl- OH 3040. 10116 (lieplooli 14R5-14 Form 3040 which easy be used) Mock Plumbot. 5

services of the United States. 0 0 If E. Is YES, is the parent on active duty? Check service below: 0 Air Force 0 Army 0 Coast Guard 0 Marines 0 National Guard 0 Navy indicate wilh an he longest. Prekindergarten Prekindergarten Parent Program Applicable (17) PRESCHOOL ENROLLMENT IsFORIAATION Place an X by e

n) (attach narrative d additional space needed) C. LABORATORY (as indicated) t- rnoglcbin/Hemafocrit Stool (O & Tuberculin test: LP 1C1 Sickle Cell d NAME: TITLE: ADDRESS: (Please Print) 1 7A /7 5 OH 3040. 10/16 (Rapacas HRS-ef Form 3040 when may 0* oseie) (Stock Nwnbsr 57444430 JU0 2)

ed services of the United States. 0 0 If E. Is YES, Is the parent on active duty? Check service below: 0 Air Force 0 Army • Coast Guard 0 Marines 0 National Guard 0 Navy (10 PRESCHOOL ENROLLMENT INFORMATION Place an X by each program attended. Also, indicate with an asterisk r ) the program your child was In the lon

Illnesses Injuries: explain) (attach narrative it additional space needed) C. LABORATORY Hemoglobin/Hematocrit Stool 1O & P) Tuberculin test: Sickle Cell Lead Authorized Signature OH 3040. 10190 (Replaces NRS-li Form 3040 which may be used) (Slack Number 5741-000-3040-2) EFTA01710221 ERs Studen

sidized Child Care 0 O. Other 0 0 If E. is YES, is the parent on active duty? Check service below: 0 Air Force • Army 0 Coast Guard 0 Marines 0 National Guard 0 Navy (17) ISIHE STUDENT A SNORE PARENT? NO 0 YES 0 NO Om CURRENT GRADE LEVEL 07 4TRANSEEWINEORMATION ;a6„...-Waiftt 09) NAME OF SCHOOL TRANSFERFtr